Mammograms can detect abnormal tissue and breast cancer. Starting in 2011, if you have Original Medicare, you will not pay a coinsurance or deductible for a screening mammogram if you see doctors who take assignment. Doctors and other health care providers who take assignment cannot charge you more than the Medicare approved amount.
If a person has no symptoms or prior history of breast cancer, Medicare will cover preventive mammograms. Medicare covers:
- One baseline mammogram for women 35 to 39 years of age
- One screening mammogram every 12 months for women ages 40 and over
Medicare will also pay for both men and women to have diagnostic mammograms more frequently than once a year. A diagnostic mammogram may be recommended when a screening mammogram shows an abnormality or when a physical exam reveals a lump. Medicare covers as many diagnostic mammograms as necessary. These mammograms are billed differently than preventive screening mammograms. There is a 20 percent coinsurance for people with Medicare who have already met the Part B deductible.
Medicare Advantage Plans, also known as private health plans, have different cost-sharing responsibilities than Original Medicare. If you are in a Medicare Advantage plan, you may have to pay a copay for mammograms. Contact your plan to find out what costs and rules apply. Medicare Advantage plans cannot require you to get a referral for a preventive screening mammogram. Starting in 2012, Medicare Advantage (MA) plans will cover all preventive services the same as Original Medicare. This means MA plans will not be allowed to charge cost-sharing fees (coinsurances, copays or deductibles) for preventive services that Original Medicare does not charge for as long as you see in-network providers. If you see providers that are not in your plan’s network, charges will typically apply.